Without doubt, one of the standout achievements over the last hundred years is the improvements made to population health. Under Queen Elizabeth II, we live nearly twice as long as we did under Queen Victoria.
Like all advances, it reaches a point where the low-hanging fruit has been easily picked and any further improvements are hard won. This creates a very real danger that we will tip into overdiagnosis and provide too much treatment. Anyone visiting their GP recently is likely to have experienced this, as they are subjected to a battery of tests, many of which are of the “just in case” variety, rather than being critical to the presenting problems.
And that is benign in comparison to more serious forms of overdiagnosis and treatment. Take the example of the menopause, rightly receiving media attention having been ignored and viewed as a taboo topic for so long. Most of what we hear about the menopause relates to the negative experiences and symptoms that some women suffer.
However, the journey through the menopause is not a universal or standardised experience. While some women will suffer, there are many others who don’t or don’t want to take up hormone replacement therapy as a treatment. Like any treatment, it is based on a calculation of risk and benefit.
While it is obviously good to ensure access to treatment for women who need it due to the menopause, an over-emphasis on this subgroup creates problems. The perception is fostered that the menopause will be negative, with an impact not just on a woman’s body, but on their mind too.
In that sense, it can lead pre-menopausal (perimenopause) women to believe that they will inevitably experience the negative aspects of the menopause that they have heard and read about, even though many won’t. Also, the positive aspects of the menopause are often lost or at least not given the same attention as the potential adverse symptoms, such as freedom from periods – reducing the chances of pregnancy and the need for contraception.
I’m not suggesting that any problems experienced as a result of the menopause can simply be overcome by a positive mental attitude, but rather that we need to provide balance when discussing the issue and ensure that this natural event doesn’t become overly medicalised.
There are other examples of where women’s health has incrementally become medicalised, not least childbirth. Many women’s lives and that of their newborn children have been saved by medical intervention, but this has come at a cost to the many others who have endured unnecessary monitoring, invasive tests and the like.
In a system as megalithic as the NHS, which has developed a risk-averse culture, all the ingredients are in place to overdiagnose and overtreat – at the expense of not just the individual’s health, but the nation’s wealth, too. Healthcare is expensive and needs to be used sparingly.
The research that informs new practice and procedures is based on averages rather than outliers. If you happen to be just a fraction outside of the parameters of the average, there is a real chance that you may not experience the benefit that the original research found.
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A useful example is that of antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), a newer generation of pills. We know that one-third of people will not derive benefit from an SSRI. While the good news is that two-thirds will gain some benefit, both groups will be given several types of SSRIs before reaching this benefit or realising that they won’t gain anything, irrespective of the type of SSRI prescribed.
This can take months and at a point in an individual’s life when the need for symptom relief is at its most acute. Added to this, the first few weeks of taking an SSRI are when adverse effects are at their greatest, and the benefit of compliance is still to be realised.
The point is that we still don’t have the knowledge or ability to determine in advance who will or won’t benefit from these types of medicines. That’s without getting into the issue of how, for many people, the causes of depression are social and environmental – making it fantasy and cruel to suggest that a tablet will somehow solve these underlying problems. This is another type of overtreatment that has engulfed millions of people in recent years.
We should acknowledge the advances that medicine has provided, but also recognise that there are limits to what can be achieved.
Ian Hamilton is a senior lecturer in addiction and mental health at the University of York